The First Breath of Autumn

I love mornings like this, early fall maple muffin mornings, with fog as thick as a cloud bank hovering over the hayfield. Freddie the Freeloading porcupine sneaking breakfast under the apple tree, unaware I'm watching. Dew on the grass that will be frost soon enough and air already cool enough to faintly see your breath. It won't last long, the mid-morning sun will see to that.

The first breath of autumn always goes fast.

Kind of like third year rotations. When you're in the starting gate, gazing down the track toward the clubhouse turn (the first curve in horse racing), six weeks appears endless. Before you know it, you're in the home stretch and the written exam lies ahead at the finish line and you're wondering what madness possessed you to think you were too weary to study after a day on the wards. Surely, you didn't need sleep that badly, did you? Yet, somehow, like Seabiscuit, you dig deep, pulling a passing grade or better out of your hat like a magician's rabbit. A weekend of freedom passes like a thief in the night and the process starts all over again

But not this time. At least not with internal medicine. IM is a twelve week test of endurance, though broken into several subgroups you get a wide glimpse at the field. Thus far, I've been on the residents' teaching service, spent eight days with a hospitalist, and Monday heralds rehab medicine. Two weeks later comes two weeks of night float and assuming I'm still afloat after that, my final two with the residents. It's not as long as it sounds, like the first breath of autumn, it goes fast.

At first, the twelve hour days are exhausting and you wonder how the residents do it, how you'll do it when you're one of them. A week and they're familiar, another and they're commonplace while you're hustling to get all your patients seen, clinical notes written and patients seen once more before evening report. If you've had an admission or accompanied a patient to a procedure, you realize this is what cranberries feel like when they're tossed into a blender at Thanksgiving and the switch clicked on.

The good thing is, it's only week six. Instead of feeling like you've just gotten accustomed to finding your way before it's time to move on, you have a chance to actually practice what you've been learning. The context in which you'll see patients will change, but it's still internal medicine. It's not as though you've been doing well-child visits, diagnosing colds, ear aches, and strep throat, and suddenly have to distinguish between major depression and an acute grief reaction. Racing to a code blue cardiac emergency is a bit different from rushing to intervene with a telephone wielding patient who checked self-control at the door to the locked psych unit.

You get used to it, we all do, but it's nice once in a while when you don't have to. When you can to get close to a patient without having say goodbye before hello has barely passed your lips. When you've grown confident walking into a hospital room without a resident holding your hand because you've done it thirty or forty or fifty times and lived to tell the tale. When you can step into the doctors' dictation room, sit down at a computer and do your business because you have business to conduct, just like the other doctors. Don't get too comfortable, though, because it won't last, it can't -- you have other things to learn, other patients to see, and like the first breath of autumn, it all goes fast.

It always does.

(Creative Commons image of autumn colors by franzikus garten via Flickr)

Doctor's Notes

Before going much further, I feel like I should apologize for not having written anything lately. The past seven and a quarter days I've been working with the hospitalist service and that includes the weekend. It's probably self-indulgence, but truthfully, our work as students doesn't end with a punch of the time clock. Anyway, thanks, as always, to any and all who've come by to see if there's anything new. I've got the next four days off and I'll try my best to make up for my laxity of late.

What's that? Oh, the hospitalist service refers to physicians who are employed by a hospital for the sole purpose of providing inpatient care. My current rotation entails spending a week to ten days working with one of them -- it's a bit like an apprenticeship -- and learning internal medicine under their tutelage. The two weeks prior were spent with family medicine residents seeing their assigned patients and it's to their service I'll report once again this coming Monday.

As healthcare delivery has changed over the years, it's pretty rare to see a family doctor or any kind of doctor, for that matter, admitting and then following their own patients in the hospital. There are still a few, mostly family practitioners in the hinterlands of upstate Maine or other remote locations, who do it the old-fashioned way, but they're a vanishing breed. For the most part, patients are evaluated in the ER and then transferred to the responsibility of a hospitalist who oversees their hospital stay.

And that's where my fellow students and I come in. We'll report to the Emergency Room, take a detailed history from the patient and/or their family members, complete a physical exam in the company of a resident or attending physician, and then become a member of their treatment team as long as they're inpatient. Sometimes the H & P (history and physical) has already been done when we arrive for rounds (morning report) and we just go on from there.

My first two weeks I spent learning how to write a clinical note. That may not sound like much, but really, it's huge. The clinical or chart or progress note -- they're all basically the same thing -- is how doctors talk to one another about a patient's condition, symptoms, and so forth. Even though I got the basic format down during my psychiatric rotation, writing a note for internal medicine takes practice and I practiced a lot. I didn't have nearly as many patients to follow as I did this past week, so I had time to write and rewrite my notes over and over to make sure I had something worth leaving in the chart.

This past week my task was slightly different. Having gotten accustomed to writing notes that were legible and covered all the clinical bases, now I had to figure out how to turn them out faster in order to keep up with my attending. But you can only write so fast before legibility gets tossed out the window and a student's note has to be readable in order for a supervisor to evaluate our thinking process. So, you learn the art of brevity, writing what is truly necessary, and generating a plan of treatment that specifically addresses a patient's symptoms that particular day. Pragmatics take precedence over literary perfection.

It's a matter of taking one step after another, one step at a time. That's really how a rotation like this one unfolds. To be of any value at all, you've got to be able to communicate about patients and since your note is a critical element in the process, you start there. It's not dramatic, no one's going to page you at the end of the day with an offer of a guest spot on Gray's Anatomy. But once in a while, an attending reads what you've got to say, decides you have a good idea, and adds the medication you suggested or obtains the consult you recommended. And right then, you got to do something good for someone. And that's really cool.


(Creative Commons image entitled "Doctor's Note" by keitamiyoshi via Flickr)

First Night On Call

Well, here I am, my first night as a medical student -- a medical anything, for that matter -- on call. In point of fact, it may not turn out to be much since I'm covering for an outpatient pediatrics practice. Most likely, any parent ringing up tonight will get the nurse practitioner who will triage the case and we'll see the child tomorrow. My job is to keep tabs on the E.R. and it's one I share with my attending

In the event a patient's parent decides tomorrow is not soon enough for Johnny or Joanie to be seen, my attending will get a call from the E.R. informing him it's time to awaken me from a sound sleep and get my eager backside down the hill from the apartment I share with another osteopathic medical student, and perform an evaluation. Then, on the assumption my attending's presence is legitimately required, I'll call back and summon him from hearth, home, and his spouse's warm feet, to join me in a game of Guess What I'm Sick With?

Should he decide his presence is not absolutely essential and his confidence in me well-placed after all, he may simply confirm my diagnosis and treatment plan, and inform the E.R. doc to implement the orders he's asked me to write and intends on signing first thing in the morning. The real morning, that is, when sane people are supposed to get up, not at 3.00 AM when night owls, insomniacs, and medical students prowl the streets looking for trouble in all the right places.

How all this came about is, I've been doing my pediatrics rotation out here in Western Massachusetts, in the Berkshire Mountains, and my assigned attending physician has taken a week off. No, it wasn't me, this has been in the hopper quite some time. So, she asked a colleague to take me on for a week and he does his own call. Noting the eager gleam in my eye when he mentioned this tidbit, naturally he didn't want to disappoint. And the truth is, I've been looking forward to tonight since my internship days in Boston, and there was no way I was going to let him have all the fun.

So, we shall see how the night unfolds. I may not do a thing. Then again, it's a full moon and as psychiatric mythology would have us believe, anything goes. It doesn't really and psych admissions are no more prevalent on full moon evenings than they are on Friday the Thirteenth. It just feels cool to say it that way and have the uninitiated think we're cool for being in the E.R. when anyone with a lick of sense would be in bed, sound asleep. But I'm not dozing this one out in an on-call room; I'm snug as a bug in my little alcove of a bedroom one step off the kitchen, where I'll be be until duty calls. Or my attending. whichever comes first.


(Photo of Berkshires Medical Center copyright 2011 by the author)

Lessons from Fred Astaire

I feel a bit like Jessie Livingstone of Pink Hats and a Mack Truck, when she likened Dr. Bob Z to George Harrison on the cover of Abbey Road (chapter 10). You know how it goes when you meet a person who strongly resembles someone famous and it's hard to get the connection out of your head. Well, it's that way with my current preceptor. He not only looks and sounds like actor/dancer Fred Astaire, the two have similar mannerisms. Not that I'm anywhere near old enough to speak about Fred from personal experience, but if you check out some of his films on Turner Classic Movies, you'll see what I mean.

I'm nearly through this rotation, sadly but also gladly, and pediatrics is looming on the horizon in the Berkshire Mountains of Western Massachusetts. Sadly because I've thoroughly enjoyed every moment in north central Maine as I've said in numerous posts, and gladly because it means I'm moving on to something new. I've gotten to work with a few younger patients on my current rotation, mostly school age and teenagers, and they've been a lot of fun. I'm looking forward to seeing more like them as well as babies and itsy-bitsy kids.

I'm especially grateful to my preceptor for his willingness to "throw me in the briar patch" of patient care. Having to call upon things I've tried out on campus and do so now, in real-life situations, has been a challenge that's forced me to address my weaknesses. You can dodge some of that in the lab, relying on your student status and the fact that your patient is a paid actor, the presumption being, you'll get it eventually. But when your patient is truly short of breath, looks like death warmed over, and tells you they feel sick as a dog, you've really got to stand and deliver. I love that. It means I have a chance to do something that can genuinely make a difference.

Now, how much can a medical student actually do? That depends. Naturally, I can't pull out the old prescription pad, scribble something down, and hand over faith and hope on a 3 x 5 piece of paper. Still in all, I can do a careful history and physical exam, try to cover as many bases as I can, and then decide on the best course of action in collaboration with my attending's greater experience. It's more practice and practice creates confidence. I can't begin to tell you how good it feels, walking into the examination room and seeing someone for the first time, knowing the tools in my kit are ones I can meaningfully use.

There was a time, not all that long ago, when my black canvas doctor's bag with all its esoterica within, seemed like an appealing stranger. Now, I carry it with me every day, and feel a little naked without it. One morning its contents were as cold as the wind blowing off the Kennebec River and the next, as warm as my dog's greeting when I come home at the end of the week. I don't know when the change occurred, but it has and I'm glad I was there to experience it for myself. I guess you could say it's what happens when you have a chance to take lessons from "Fred Astaire."


(Creative Commons image of Fred Astaire and Ginger Rogers on the cover of Life Magazine, 1938, by Zooomabooma via Flickr)

Surviving Board Exams Revisited

According to a handy-dandy little application provided by Blogger, Google's blogging support system, one of my most commonly read posts is Surviving Board Exams, written last summer after attempting boards for the second time. I've thought about this post and its popularity, and it seems to me the title is mildly deceptive, though certainly not intentionally so. It sounds like strategies for getting through medical licensing exams when in fact, it was a reflection on my post-exam experience at the time. And that's the important thing to remember, because, as it turned out, I was to take the that portion of our osteopathic boards once more before gaining a passing score.

Veterans come in all shapes and sizes. There are those who've served in the military, those who've come through hard times -- veterans of addiction, abuse, or grief and loss. I've even used the term to refer to the bond that develops between medical students or between residents in the course of their training. Just this past week, while visiting with a friend who had lost a parent, I mentioned the word "veteran" describing those of us who have lost one or both parents. My friend looked me in the eyes and said, "It's just that way, isn't it?" And it is.

Some things are so profound that our endurance of them can only be fully comprehended by one who has been down the same dark passageway in one way or another. We do our best to empathize in these situations, calling upon our personal histories with suffering, but "you had to have been there" is a phrase pregnant with truth. This doesn't mean we ought to throw up our hands and throw in the towel, abandoning persons in distress to their own devices, but empathy has its limits and we do well to recognize them, while offering the very best of the empathy we have to share.

My perspective on board exams, like that of many other medical students, is colored by trial and failure, as well as success. Looking back a couple of years, I can see how I fell victim to pressures exerted by the expectation that medical school follows a predictable time line. The longer I'm immersed in this process, the more I realize predictability is a delightful fiction. Circumstances appear that no one can anticipate, altering one's time of arrival at the railway station called "Graduation." And it happens more often than most people realize.

For me, surviving board exams became a reality as a direct consequence of attending the PASS Program in Champaign, Illinois last fall. There I learned how my previous attempts were pretty much doomed to failure because I, like most students, had misunderstood the nature of boards. I thought they tested what I knew and in reality, they test what I can use. 

Since the first two years of medical school focus on the accumulation of medical knowledge rather than its clinical application, when we face boards for the first time, we're at a distinct disadvantage. Failure is so devastating because we're inclined to take it as a judgment upon what we know, suggesting we either haven't learned enough or our learning mechanism is faulty. Both damage self-esteem and erode self-confidence, the very qualities we need to hold onto the most.

In my experience, after receiving a failing grade on boards, the first thing students do -- and I did -- is engage in a more intense review of the material they studied the first time around. Usually they supplement an already massive amount with notes, charts, and review books, on the presupposition their previous preparation was inadequate. That approach, however, perpetuates the misconception that boards test how much you know. In many cases, we already possess sufficient knowledge for the task, we just don't know what to do with it. Learning how to think clinically and discern the patterns in medical science is the critical chapter in Beggar's Survival Guide for Medical Board Exams. 

But even the experience of failure and discovering how to approach boards successfully has been a valuable one for me, because I've been able to share it with others in similar straits. Having a failing grade on boards, according to the common wisdom, is a liability when it comes to obtaining residency placement. I'm not saying it's not, but I am saying grace has a way of seeing us through when we fear there is nothing that can. When we refuse to call any experience wasted and take it instead, as something to hold in reserve until we can use it to help someone else, the benevolence of the universe, the grace of God -- whatever you wish to call it -- has a habit of acting on our behalf.

Maybe we don't get a premier spot in the most competitive and prestigious of residencies, but when we use what we have to help others we gain their love and appreciation. We grow in our capacity to give, we become better persons, and all of that is so incredibly worthy, the day can come when we are grateful for every time we've stumbled, fallen, and gotten back up along life's way, because without them, we'd never had the privilege of helping someone else.

(Creative Commons image by ross6606 via Flickr)

The Lucky One

I'm home again after another amazing week in rural Maine. I gave my first tetanus shot yesterday and identified, if not actually diagnosed, my first case of outpatient pneumonia. The latter was a biggie for me since we didn't have a chest x-ray to rely on; instead, it was a matter of taking a careful history and listening to our patient's breathing, then asking what was the most likely explanation for their presentation. As I've mentioned previously, I can't get over how much more akin to internal medicine this rotation is turning out to be.

In part, this is due to the fact that my preceptor's patient population is, by and large, an older one, so the colds, flu, measles, and chickenpox that show up in family medicine don't walk through his door too often. It also stems from his comfort level, dealing with difficult and challenging cases. He won't admit it -- something I admire about him -- but he's a careful and astute diagnostician. He takes his time with patients and encourages me to do likewise and make certain I offer well-reasoned and thorough explanations for what we're doing and why.

More than accurate explanations, he wants to make sure we provide ones that are comprehensible. This appeals to me strongly because it's the same principle my friend Dr. Lynn Smith and I followed when writing our book. We wanted to communicate effectively, not impress readers with the extent of our vocabulary, something that often characterizes academic writing. "It's not what you say or do," my preceptor reminds me over and again, "it's what people think you said," that matters. For this reason, you want to make certain what they think is the closest approximation of what you actually said, as possible.

So, for example, when urging a patient to take a complete course of antibiotics and not stop once they begin feeling better, he'll say, "It's like wolves who attack the weak and sickly in a herd of deer and then go after the strong." An antibiotic kills off the weaker members of a bacterial population in the initial few days of taking it, but you've got to finish the prescription in order to get the ones that remain after you've started to improve. Makes a lot of sense, doesn't it?

I'm three weeks down in what's usually a four week rotation but I've been offered the chance to extend it by another two, and that's what I'm doing. I'm learning too much and having too much fun in the process to turn down the opportunity. Of one thing I'm certain, when I graduate, whatever kind of physician I'll become, it will be strongly colored by the weeks I've spent with this guy and his gal Friday in north central Maine. Am I ever the lucky one.


(Creative Commons image of the Kennebec River Valley by jimmywayne via Flickr)

Coping with Both/And

Image via WikipediaWant to know what the hardest thing is about family medicine -- for me, that is? Explaining to family doctors why I want to be something else. And doing so in a way that doesn't hurt anyone's feelings or give the impression I'm not interested in medicine. Trust me, this is no mean task, especially when doing a family or internal medicine rotation. You see, as a student, I want to get the best education I can. But this tends to create confusion because, somewhere along the line, psychiatry has gotten the reputation of being the discipline for those who don't have the hots for medicine. Making it tricky for those of us who do.

Like most generalizations, this one doesn't hold true in every case. Still, it holds true in enough of them that it becomes necessary for the rest of us to try to overcome the stereotype. But here's the rub: if I act motivated to learn physical medicine, it calls my commitment to psychiatry into question. If I act like all I'm interested in is psychiatry, then I may not be taken as seriously as the student who identifies with Marcus Welby, Ben Casey, Doug Ross, or Alex Karey, MD or DO, depending on which generation of television doctors you follow. Damned if I do and damned if I don't.

To be fair, I'm sure it must be the same for students whose stated intention of becoming "doctors" is complicated by an interest in patients' psychiatric conditions. Both/and isn't the easiest thing to cope with on the best of days. Now, it's entirely possible that those appear medically-ambivalent might actually be happier with advanced degrees in psychology. I don't know, I'm just saying. You can definitely count on medicine involving you with patients in ways you don't have to think about as a psychologist.

Take this past Thursday, for example. The only other time I've performed a male (why do we call it that? I mean, is there any other kind?) prostate exam was in lab one evening a little over a year ago. On the same occasion, I did my first female breast and uterine exam, both with actor-patients to whom and for whom I will be eternally grateful. As you may know first-hand, exams like these are a very intimate, for doctors and patients alike. And they're things a psychologist doesn't ever do.

It's true, psychiatrists don't routinely do prostate exams or pap smears, but that's not the point. They receive this kind of training because they're in training to become doctors and therefore, approach the brain-mind-behavior interface from the standpoint of one who practices medicine, not psychology. As an aside, this is one of my objections to allowing psychologists to prescribe psychoactive medications, but that's for another day. Call me narrow-minded, but I don't think one can be a competent psychiatrist without being a competent physician for the very reason that psychiatry is the medical discipline whose task is to tread the no-man's land between mind and body.

St. Augustine, Bishop of Hippo (not of hippopotamuses, though I certainly have no objection to the idea -- ever attend a blessing of the animals on the Feast of St. Francis of Assisi?) in Northern Africa during the fourth century, prayed, "God, deliver me from the need to justify myself." I guess I'm not there, yet, but God knows my heart and I think my preceptor in rural Maine does as well, because he surely gives my desire to learn physical medicine the same attention he does my interest in psychiatry. It's just a matter of coping with the stereotype in subsequent rotations and I guess that involves being gently and respectfully honest and letting the chips fall where they may. It's nice to know Augustine struggled, too. I feel like I'm in good company.


(Fair use of a copyrighted image of George Clooney as Dr. Doug Ross from "ER" claimed for the purpose of identifying the character in question with no commercial intent and in the absence of a similar, free image)

A Real Country Doctor

Image via Wikipedia
Well, I'm home for the weekend, having gotten away early, following a short day in the clinic, and I've got to say I'm enjoying this rural medicine rotation immensely. In part, I'm sure it has to do with the fact that I'm personally getting to see at least a couple of patients each day on my own before we're joined by my preceptor, and today there were three, all in a row.

I can't begin to tell you how good it feels to do this once again, after such a long dry spell. It's been four years since my little cubbyhole of an office in Denver where I sat with patients, argued with managed care, and dreamed of being a doctor. Walking into an examination room, now, and greeting someone I've never met, asking them what brings them to the clinic, is so much like coming home it's almost beyond words.

What has surprised me about the experience thus far is how much fun I'm having. Previously, my encounters with family medicine have been so-so. Not bad, but not great, either. This time, I can hardly wait to get to the office at 8.30, about the time the nurse-receptionist-office manager-cheer leader in residence and anything else you want to call her, arrives. She's got a wry sense of humor that is wonderful and she knows medicine inside-out. I told her today that when her boss retires, she may as well forget about retiring herself, because I'm hiring her next.

By nine, my preceptor arrives, and the first patient shortly thereafter. If we having breathing room, we'll see this one together. If it's like this morning, the nurse has one lined up for both of us and I'm in heaven. Thirty minutes later, I report to him what I've found and we round on the patient together. There is always a teaching moment somewhere in the mix and I'm amazed at how much he knows and how much I'm learning. And this has only been the first week.

I'm glad to be home, to have a chance to walk my dog and cuddle with the cat, to clear the fresh snow away from the barn and dig out my mailbox that's buried forty inches deep with more snow on the way. But you know? I honestly can hardly wait for Monday to come. I'm seeing diseases I've only read about the past few years, evaluating patients with a growing confidence, and learning about medicine in a way that makes me wish I could scan my preceptor and his nurse into my iphone and carry them with me right through residency. He's a real country doctor and I'm a country boy who's having the time of his life.


(Pubic Domain image via Wikipedia)

Rotations: Day Two

There's no question about it, I'm definitely enjoying this rotation. For one thing, as a friend reminded me yesterday, the techniques tend to come back once we start using them. I think muscle memory plays a role here, the hands remembering things the mind thinks it's forgotten. An understanding supervisor makes a tremendous difference, her ability to recall what it's like being in shoes similar to mine drives away the tension. Forgiving patients who tolerate my fumbling efforts and offer thanks when leaving, make me think there's hope for me yet.

Something I'm noticing more and more is how common some types of dysfunction tend to be. One patient has a rotated pelvic bone and then another and another after that. In lab we see this sort of thing in isolation from daily life. They're exercises rather than the lived experience of someone in pain. And for the most part, a rotated pelvis isn't the primary consideration, but addressing it enables a person to walk with less stress and strain, placing fewer demands on the rest of the body to compensate. When my supervisor tells me to examine and treat what I find and then returns later to check my work and responds with a pleased, "Mm," it's gratifying to say the least.

I've mentioned at least a few thousand times before that I'm a psychiatric guy. I see patients with physical problems and can't help but look at their facial expressions and listen for the energy or the lack of it in their voice and speech patterns. How does pain affect a person in ways we can't see? And how do these signs change as treatment progresses? I love the friendly banter my supervisor engages in with patients and encourages from me. It's a chance to loosen tight muscles by drawing personality into the mix.

The beauty of working in an established practice is you get to work with patients who aren't new to OMM. They're accustomed to having relative strangers touch them in really quite intimate ways and I marvel at their trust. I'm grateful for this, especially, because it helps me think of myself as a medical clinician, doing the best I can to help them feel better, while learning as I go. Their willingness to allow my unfamiliar fingers to probe and manipulate is turning each day into one marked by self-discovery, by the process of finding the healer within me that I have so frequently admired and sought to emulate within others. I don't know how they do it but I'm very glad they do.


(Creative Commons image entitled "M is for Muscle Memory" by stuant63 via Flickr)

Pink Hats, 12: The Medical Student Pipeline

Never stand when you can sit, never sit when you can lie down, and never pass up an opportunity to eat because you don't know when you'll get another, was the advice his best friend, an MD psychiatrist, passed along to him from his third year, which was given to him by a fourth year student who'd gotten it from her intern. 

That's how things work in medicine. Not quite a pipeline but close -- you could call it an oral tradition. Composed of wisdom, humor, and hopefully, sound common sense, Jung would describe it as the mythology of medicine, a body of useful tidbits that works its way into the psyche and helps transform dreamers into initiates.

Day Two of his rotation burned up his breakfast glucose faster than a speeding bullet, and Chuck was grateful the matronly cafeteria employee who filled his plate believed in generous portions. He was deep into his macaroni and low-fat cheese -- the cheapest entree on the menu -- with a side of salad and apple pie, when Jessie set down her tray and asked, "Mind if I join you?"

"No, by all means, do. How are things with you?" He was surprised at the company, thinking she could have chosen the doc's lounge, instead.

"Busy, as usual. I just had to steal a few minutes, though, to nosh down a sandwich -- I was bonking big time. How about you? How's your second day with Dr. Bob going?"

"Amazing. We saw three colds, a case of croup, four of impetigo, one kid with measles, and, as he puts it, a whole lot of distraught, at-their-wits-end parents, as well as a rule/out case of pneumonia before he said, 'Get out of here, go get lunch, and I'll see you in 30 minutes.' I don't know much yet, but when my attending says, 'eat,' I make it a point of doing exactly as I'm told," he said, smiling.

She nodded knowingly, wiping an errant smear of mayo with a the tip of her middle finger. "I can identify and believe me, that's smart. He'll have you working up your own patients sooner than you realize and time will get even more precious. My suggestion is, familiarize yourself with the most common childhood diseases -- he won't give you a 'zebra,' not at first. If he thinks you can handle it later on, maybe. Keep in mind, with him, how well you know your patients is as important as how well you treat them. In his book, kids are first of all, people. But I'm guessing that might not be much trouble for you."

"Why do you say that?" he asked, taking a sip of Pepsi One.

"Well, you're an older student. Even if you haven't had any medical experience, you've have life experience and that gives you a distinct advantage when dealing with parents. They'll assume you more than you do, which means they'll be less inclined to regard you as 'merely a student.' That was something I had to overcome in my rotations."

"I was a therapist -- psycho -- before medical school, but I'm 'as green as a boy can be,' as Mark Cohn would say, when it comes to physical medicine."

"I like that song, too, and your experience as a therapist will help you immensely since you already know how to listen, presumably. Parents will appreciate you listening to them, but do it with their kids, too. Doctors don't listen to kids nearly enough. So, look for clue words, ask pertinent questions, summarize to make sure you're all on the same page, write up your notes carefully, and you'll be fine. You'll learn more than you ever thought possible and have fun at the same time."

"Thanks for the advice -- and the encouragement. How long have you known Bob? He insisted I use his first name -- 'If I can call you Chuck, it's only fair for you to call me Bob. Besides, if I can persuade you to become a pediatrician, one day we'll be colleagues.'"

"That's good. Since med school, like you." She concentrated on her sandwich, washing it down with iced tea, and hoping he'd leave it at that.

The brevity of her response struck him as curious, but since she wasn't paying for therapy, he decided to drop it for the moment and changed the subject. "One thing, it was really cool seeing the twins with him yesterday. I was blown away by how much they've grown."

"Oh, they have, and thanks to you and your dog -- it's a Lab, isn't it? I've got one, too -- they've become the darlings of the peds unit. You did a four-oh job that day, in case no one's told you. Seriously. Bob told me about the EMT report -- you saved their lives."

He used his last forkful of apple pie to hide his self-consciousness and said, not having quite finished chewing, "Well --" munch, "it was --" sorry, let me finish this." Munch, swallow, sip of Pepsi. "It was scary, that's for sure. You know how it goes, first you've got that parasympathetic response and you think you're going to wet your pants, then the sympathetic kicks in and the adrenaline flows. The truth is, I didn't do much at all, it seems like. The guys from the fire department were terrific -- I have never in my life been so glad to hear a siren. Oh -- yeah, he's a Lab, a yellow one -- Chester."

Finished with her sandwich, she drained her tea, and started to get up. "Mine's Black -- Sam, and we're all glad to have you here, especially Bob and I. That's why I decided to eat in the cafeteria, I saw you come in and thought it would be an opportunity to say so. Anyway, thanks for the table -- I'm sure we'll talk again." I can't believe I said, 'Bob and I' -- me and my big mouth.

"That is so thoughtful of you to say, it really means a lot." As she walked away he mused, Mm, 'especially Bob and I' -- what's that about, I wonder...?"

(Creative Commons image of the Old Victorian Wing of Maine Medical Center, misfitgirl via Flickr)

What Makes It So Good

Morning "Number Two" time has the potential to be pretty significant around here. Mother Nature beckons to my dog, usually within 30 minutes of breakfast, and he firmly passes the word along to me in no uncertain terms, "You'll take me out now, if you know what's good for you." At that point, we bundle up, walk down the lane a dozen yards or so and on the way back, voila!

For him, this little outing is an aperitif, the main course being his walk in the afternoon. For me, it's an opportunity to let my brain unravel in the cool air. With this morning's unraveling, I think I may have finally figured out what makes the PASS Program work so well.

When I was a college student, immediately following high school, a friend told me, Christianity is not a religion, it's a relationship. This describes the PASS Program perfectly. It's not a method of board preparation that can be circulated in manual form and purchased at your local bookstore, though they do employ various techniques as I've stated in other posts. Nor is it an approach that can be packaged and franchised like a businesses concept. The heart of the PASS Program is reflected in the quality of relationships that develop between students and faculty and have the capability of taking us to the next level in our training. The word mentoring comes to mind.

But it's mentoring with a therapeutic twist. In psychotherapy, one may absorb a patient's experience and in the process, detoxify it so that a patient learns to live with their history without being overcome by it. Shame and discouragement have a nasty habit of accumulating, and in the life of a medical student, previously failed attempts at passing boards can result in one getting a heavy dose of both. Establishing relationships with physicians who are unashamed to admit their own frailties, and doing so while learning and thinking about medical science at the same time, is both empowering and liberating.

I suspect one of the reasons why I keep coming back to my experiences in Champaign in this blog is the enduring sense that I've been among some very special people. I admire those who are dedicated to building others up because there's so much in this world that endeavors to tear them down. When you've been in the presence of such persons, you come away feeling not only revitalized but more yourself. Had I attended the PASS Program a year ago, my life would be very different than it is now. Still, I'm not sure it would have been as meaningful to me as it has become after having been hammered twice by boards, and there's a great deal to be said for that. Some things only come along when we're ready and being ready is what makes it so good when they do.


(Photo copyright 2010 by the author)

Discerning the Patterns

Only a week ago I was sitting on my patio in Champaign, Illinois, wrapped in a blanket against the cold, studying clue words in the final push before my board exam on Tuesday. Since then, I've been thinking about the take-home points from the past eight weeks and asking myself how they might apply to medical education at large. The trouble is, the PASS Program is so unique in its approach and effective in its delivery, an application of its principles might necessitate completely revamping the way we train medical students. Some would say that's an idea whose time has come. Rather than engage that debate, I'd like to simply allow the lessons I learned to speak for themselves.

One of the first things you discover upon arrival is, every staff person has either been a practicing physician or is applying for residency. This means they've had to sit for boards and thus, know what it's like to have been in shoes that pinch as tightly as yours. The element of personal experience creates fertile ground for establishing an empathic relationship that is instructive, encouraging, sometimes therapeutic, and very, very human. Some are graduates of the Program and know first-hand how to use its principles successfully. They're battle-hardened veterans, we're green recruits; they've been under fire and know how to survive; we do our best to pay close attention.

Now, despite having the initial four weeks of lecture feel like our first two years trimmed down to the essential of the essentials, the learning atmosphere at PASS is devoid of the competitiveness often associated with medical school. Partly, this is due to the fact that we've all completed our required courses and our common goal is to pass boards. But even in the classroom and small group sessions, if a student is stumped, the watchword is, "Can someone help so and so out?" No one tries to beat anyone else to the punch in the hope of gaining the instructor's recognition or approval. Support is taken seriously because so many have experienced failure and we're here to learn from and overcome our failures, not reenact them.

The material is the silent partner in the whole process. We've all been exposed to an overwhelming amount of information in medical school and I'm not sure a great deal can be done about that without doing damage to what we're about. However, the PASS Program focuses on what is truly high yield, for boards as well as rotations. And that's a surprise. Most of us thought we were going to address board exams exclusively; lo and behold, we're also being trained to be more effective in the clinical setting.

How the material is presented is as important as its content. Many, including yours truly, come to Champaign thinking their frustration with boards is due to a defect in memorization skills. We're informed on the first day that our problem stems from a basic misunderstanding of the nature of boards. They aren't intended to test what we know, but rather what we can use. Our mistake was in assuming memorization was the best way to prepare. It's far better to understand the material because then it becomes a tool for problem-solving rather than a reason to go hunting for Alka-Seltzer.

The metaphor that has stuck in my mind in this regard relates memory to enzyme functioning. Enzymes break big chemicals down into smaller ones so the body can use them for energy and to promote health and well-being. But every enzyme has a limit; it can only do so much work before it hits the wall. I can identify with that. So, once the enzyme is working at maximum capacity, the only way to get it to do more work is to increase what we call the substrate concentration. Basically, this means we add more chemical so that it competes for spots on the enzyme where it can be broken down.

How does this apply to memory? Well, it seems that short-term memory or RAM, to borrow from computer lingo, is like an enzyme: it has a maximum capacity. Once you've gotten it loaded down with facts, figures, statistics, and who knows what all, it's full. To remember more, you have to start forgetting a few things and that's what happens when a person prepares for a test. They've studied for days and they think they're ready at last when that pretty young medical student from Colorado (sorry, I have to give the honor to my home state) comes along and whoops! there goes a few hundred facts. Our guy asks her out after the test and there goes another few hundred. Next day he walks into the lecture hall and his mind is as blank as a slate and he wonders what happened.
The way to combat this normal state of affairs is by making connections, discerning the patterns and relying on useful and reliable concepts that provide the framework for learning. In this way, the instructors at PASS teach us how to reduce our obsessive reliance on rote memorization and replace it with understanding. In itself, this isn't revolutionary, but the way it is applied makes it feel that way.

You see, pattern recognition is one of the primary ways the brain processes and stores information. Take vasculitis (inflammation affecting the veins and arteries), for example. Once you've discerned the general pattern that characterizes this condition, the individual types of vasculitis can be identified by clue words specific to each. A memory tool? You could call it that but I'd say it's more like using an enzyme to break down a complicated system of disease categorization into a form that makes sense. Research scientists might cringe at the thought, but they don't have to take medical boards and neither do they have to stand at a patient's bedside. If all of this sounds simple, it is, and that's the beauty of it. "Simple" may be less impressive but if it renders a concept more accessible on an exam or in a clinical situation, isn't that the whole point?

Don't get me wrong, the Program isn't a Stupid's Guide to Medical Boards Exams. I came away with a notebook filled with notes and lecture material to the tune of some 500 pages. It's four solid weeks of eight hours a day worth of hard work. My classmates and I went home at night weary and bleary-eyed , as did our instructors who were on the job long after we were eating dinner. The additional four weeks I spent studying, trying to absorb and integrate what I'd learned, was invaluable and I feel safe in saying I'll still be doing that very thing for months to come.

There is another element in the PASS Program and it's not, strictly speaking, academic; it's pastoral. Failing to succeed at boards can shake a person's confidence and damage their self-esteem. You put your heart and soul into preparing for what you fear may be the exam of your life, you get your score report and it reads, "Sorry, Charlie, Starkist only wants the best tuna." Is there ever a time when a medical student feels lower? I doubt it. They know this at PASS, many of the faculty having had their own run-ins with failure and frustration, and so they place recovery of faith in yourself, your intelligence, and your ability to tackle boards and medical wards at the forefront. When you arrive, you feel battered, black, and blue. When you leave, the bruises have healed and you're ready to ask, what's next. Treating students like persons and whole ones at that, is the most osteopathic thing they do. And most of them are MDs.

How about that?!

(Photo of the PASS Program Center copyright 2010 by the author)

A Fellowship of Failure

It's fair-skies and 48 this morning and the view from my patio penthouse includes the sun trying to reach me through the cottonwoods. Maybe by mid-October they'll feel more generous, but right now they're holding onto their leaves as though the last days of summer depended entirely on them. If they know Wednesday evening saw the Autumnal Equinox, they're not telling.

I was thinking, the other day, about the one thing nearly all of us have in common (aside from being medical students) -- failure. Some, to be sure, come simply as a supplement to their education -- not a bad idea at all, frankly. They’ve yet take their stand in the middle of some dusty street at high noon while spectators scurry for safety and then anxiously peer from windows or peek around corners, waiting for the bad guy (board exams) to go for his gun. But, they're in the minority; most of us have had that experience already, at least once, and the outcome hasn't been pretty.

I suppose this is why we’re inclined to be accepting of one another, why no one sighs impatiently when another student doesn’t correctly answer a professor's question, why hands don't shoot up like a flock of geese startled by sudden movement, eager to show they know what you don’t. Perhaps this is why asking the instructor to repeat a point isn't accompanied by snickers and rolling eyes and why busy hands copy down what their owners also missed the first time around.

I've often wondered, quite truly, what it would be like if a class was almost entirely composed of people like me. Not like me in the sense that everyone has creaky knees (I've known athletes with them in their 20s, by the way, so there) or can't wait for the 9:30 coffee break. Nor people like me who pound the treadmill in the late afternoon hoping to generate sufficient energy to keep the Rack Monster aka Mr. Sandman at bay long enough to spend the evening studying. 

 

I mean people who've had to wrestle with medical school – people like Jacob, who dared wrestle with an angel, holding onto him with all his might and through gritted teeth declaring, "I will absolutely not let you go until you bless me." People who, like Jacob, got the blessing all right, but had to pay for it when the angel dislocated his hip, so that he walked with a limp the rest of his life.

People like that.

Well, now I know. To tell you the truth, it's been refreshing. For one thing, it's delightful seeing the faces of my MD colleagues light up when I've done a little osteopathic manipulation on their cramping wrists after a day of writing like their lives depended on it. They've heard about our little secret, they know us DO types can do things with our hands they never learn, but seeing it up close and personally, they act like any one of us would when a magician pulls a rabbit from a hat and this time you know the magic is real.

More than that, it's good being among persons who’ve seen failure face to face and are determined to not let it define them. Part of this stems from the atmosphere created by our professor who knows from his own experience what it's like to have a dream behave like your nemesis. Medical school was hard for him, too. So was life, growing up on the South Side of Chicago. In his family, new clothes meant a trip to the Goodwill, not Macy's. He told us his story yesterday, holding back none of the unpleasantness, describing how he discovered the Faith that changed his life.

He reminds me of something I wrote in my very first blog post, i.e. he's one beggar sharing with others where he's found bread and then showing them how they can find it for themselves. In so doing, he inspires confidence when things seemed very much in doubt. As you walk in the main entrance, six metal letters are arranged on the counter in front of you, spelling out the word "Believe." Every day, someone on the staff drives home the message that our achievements depend as much on faith in ourselves and each other, as they do hard work. In this fellowship of failure, I suppose you could call it, we're becoming not only better future doctors, but better people. Little did we know.

(Photo copyright 2010 by the author)

Hard Places

Good Morning, Happy Sunday, Greetings from the Trenches.

The sky from my patio perch is cloudy gray mixed with distance blue; I'm not complaining, though, because it's pleasantly cool. By Tuesday, it will be in the 90s again, as autumn continues to play a waiting game here.

I had an interesting conversation over breakfast this morning with one of my roommates, who happens to be a veteran as well as medical student. Despite my having not served, it wasn't hard to establish a meaningful connection. For one thing, I know the life and for another, at least right now, we're in the same foxhole. And even after we've advanced past the current obstacle, we'll always be comrades in arms.

This is something I can't ever quite get over. It surfaced the other night as well, while chatting with a young woman who is a student in a neighboring state. One minute we were strangers and two days later, we're pals. I'm talking, of course, about the instant intimacy that so easily develops between medical students and physicians. To a certain extent, it's as though our radar is attuned to picking up on another of our own kind.

Part of this may be simply due to the fact that we're all immersed in a community of intuitive types, but I've run into it in other contexts as well. Medical ones, that is. Where it hasn't always been so readily apparent, oddly enough, has been among ministerial colleagues. I've often wondered about that and I really haven't come up with a satisfying explanation. I've noticed that whenever I've met up with a minister who's been battered by a pastoral experience or had some sort of personal crisis like a divorce, the camaraderie is there, right off.

Just thinking out loud for a minute, I wonder if hardship is what makes the difference. Seminary is tough, make no mistake, but it's not tough in the sense that it confronts inadequate defenses, teaching you to build up new ones in their place. The ministerial focus is on formation, challenging one's thinking processes and predispositions, but it seems less painful in retrospect. As a result, it's not until life gets to that point, i.e. painful, that collegiality becomes so important.

As you've probably guessed, I'm not one of those who thinks pain is, by definition, a bad thing. Where it takes us can be destructive or constructive, depending on our disposition and willingness to change in response to its presence. The more willing we are to adapt, the more benefit we obtain. It's only when we become stubborn, resistant, and determined to head-butt our way through circumstances that are less amenable to power-oriented approaches that we come away with a headache.

Furthermore, it seems we most often find kindred spirits when we're in situations that tax our abilities to cope. Speaking for myself, those relationships are the ones I value most, those formed in hard places with persons I've never met, who nevertheless know what it's like to be me. And among whom I know what it's like, being them.


(Creative Commons image by Te55 via Flickr)

The Category of Impossible Things

Why, sometimes I've believed as many as six impossible things before breakfast.~ Lewis Carroll, Through the Looking Glass and What Alice Found There

Occasionally someone who's genuinely curious but has no personal interest in becoming a physician, asks me if there are advantages to attending medical school as an older student. This is a hard question because it sounds like they're asking if there is something to be gained by putting medical school off until later in life. I can say with confidence, that was never my plan. As a matter of fact, there have been numerous occasions along the way when I've wished the path of my life had led to medical school, but I couldn't see how to alter my direction at the time. Consequently, the choices I made and continued to make only reinforced the route I had already taken.

What I believe people are really wondering when they bring up the subject of "advantages" is, "Are there good reasons for pursuing medical school later in life?" Now, that is a question I can answer, having decided for myself, there definitely were. And those take a person into the realm, into the category, of impossible things, and I'm convinced that's where medical school (and graduate school, generally speaking) dwells.

It's the nature of impossible things to expect and even demand more than any person could possibly deliver and presume it's perfectly normal to do so. At some point, I'd wager every medical student comes to this conclusion, no matter what their age. It just feels that way.

Impossible doesn't mean it can't be done, because it can and this is where we get to the good reasons part, one of them being, it's impossible not to go, i.e. it's impossible to delay any longer. A person arrives at a point where they realize there is a life within them that will remain unfulfilled unless they do something about it. And, frankly, refusing to leap into whatever darkness they will face seems more unbearable than anything they might encounter afterward.

This is all deeply personal, but to my way of thinking, the best of the good reasons comes down to the only reason: it's something you have to do. It's the kind of decision that conditions all of those to follow. Whether it comes about as the desire to go to seminary, attend college for the first time, or try to enter medical school, when the heart speaks, you are compelled to listen. And then, you close your eyes, cross your fingers, whisper a silent prayer to whomever you hope is listening, and step across the threshold into the Looking Glass.

Come what may.


(Creative Commons image of Alice Through the Looking Glass by sammydavisdog via Flickr)

An Unlived Potential

I've been reflecting on yesterday's post about the film Avatar and others like it, where the lead character encounters a way of life with which they have little in common and yet, it is in this context they are enabled to grow to mature personhood. One thing that occurs to me is, often as not, these characters also appear out of step with their own world. They try to fit in but something inhibits their doing so fully. Maybe it's physical, maybe it's psychological, but one way or another they've arrived at a point where they're ready for something new.

Not new in the sense one is bored with the same old dull routine -- it's not like that. It's a qualitative newness that alters perceptions and challenges preconceptions. Change is in the air and they're ready to inhale it deeply. You can't think your way into a place like this; it's instinctive and either you're there or you're not. It comes about less by expectancy than by happenstance, and then reveals itself in a manner that suggests it's just been standing in the wings, waiting for us to make room for it onstage.

Another thing I've noticed is, there is always a community involved that views the lead character differently from the way they've viewed themselves. For instance, in Avatar, Sulley identifies himself as having been a "warrior" among the sky-people, and the Na'vi inform him this does not automatically qualify him to be one in their society. It's kind of like coming to medical school with a clinical background and discovering you need to start over at the beginning like everyone else. There are no special cases.

As the process of "becoming" proceeds, I think the community is the key player; it creates an atmosphere of support and appreciation in which lead characters become open and honest. The self-doubt and worry that plagued them in "our world" is worked out like a garment stain scrubbed vigorously on a wash board, and they begin looking peaceful and secure in their unfolding identity.

I realize one could say such communities as the Na'vi are idealized and sure, that's true. But they don't have to be, nor should one necessarily need to go to another planet to find them. Whenever we're around persons who value an indescribable something within us, and that experience makes us want to live up to their vision of us, then we've found a nurturing community. And what they see, we've felt was always there and because no one called or beckoned for it to come out of the shadows, it remained an unlived potential. But in the light shed by the community, it thrives, contributes, and makes us feel we're where we were always meant to be. And we probably are.


(Creative Commons image "Community Balloon" by sebastien b via Flickr)

Bipolar Disorder in The Informant!

Creating a realistic visual representation of mental illness on film has not always been Hollywood's strong suit, but I think it's getting better. Having a sophisticated audience that expects more than theatrics, helps. While The Informant! is, strictly speaking, about Mark Whitacre's corporate whistle-blowing while a vice-president at Archer Daniels Midland (ADM), it also gives us an interesting look at bipolar disorder (formerly manic-depression).

What usually comes to mind, when this condition is mentioned, is alternating cycles of depressed, and then manic, episodes. In truth, as with other types of psychopathology, bipolar disorder can be manifest in several ways, such as mostly depressed with rare and mild manic phases, or predominantly manic with little observable depression.
Matt Damon plays Whitacre, who becomes an informant in an FBI investigation of price-fixing. Over time, Whitacre himself is accused of price-fixing and money laundering and comes under investigation. Throughout the film, we're treated to an ongoing stage whisper, a monologue in which Damon addresses the audience, revealing his character's thought process.

Prone to grandiose delusions, Whitacre imagines himself as the only person sufficiently and uniquely qualified to take over as CEO of ADM once his superiors have been removed because of their illegal activities. Portrayed as someone whose "internal power generator" is switched on a little too high, he goes through a period where he sleeps little, spends unnecessarily, and becomes so entranced by the investigative process that even the FBI question his motives.

Initially, I wasn't at all certain about Damon's character, because of the way he lies so frequently and convincingly. By the end of the film, the lies have become so interwoven and convoluted, not only were the other players confused, my head was spinning. Ordinarily when one sees that kind of thing, they think "narcissistic" or "antisocial" personality traits, but Whitacre doesn't come off as either of these. It's not as though he knows the truth and wants to deliberately deceive, as much as he sees himself as the author of a grand drama, making up the storyline lie by lie as he goes along. And honestly, I think his delusions eventually get so complicated, half the time even he doesn't know he's lying.


Near the end of the film, the judge in the case against Whitacre determines bipolar disorder has had nothing to do with the charges brought against him. I think this reflects the difficulty many have believing that someone can act like this character does, and not be in complete control of their faculties. Their behavior is goal-directed, seems intentional, and it is, but it's based on a mental rearrangement of reality that has little connection with the experience of the rest of us. 
The Informant! is a dizzying account that spans several years in Whitacre's life when the stresses generated by his employers and worsened by investigation, combined with undiagnosed and untreated bipolar disorder to induce manic behavior. It's a tragic story in a lot of ways -- Whitacre ends up in prison and is released in the final scene -- but it's also fascinating to see how his condition co-opted his better judgment. It's a film well worth seeing, but be prepared to feel out of breath while trying to keep up with the main character.


(Creative Commons image of a PhotonQ pre-screen of The Informant!by PhOtOnQuAnTiQuE via Flickr)

In Excess of Survival

There once was a man named Job. He was a good man and over the years, accumulated everything that mattered to him as well as to most of us -- family, financial security, health -- until one day the roof caved in and through no fault of his own, he lost it all. His friends commiserated with him, saying "Life has dealt more harshly with you than one should have to bear -- curse God and die." I don't know whether they wearied of witnessing his spectacle or of hearing his lament, but it's easy to talk about death when it's not at your doorstep. Job refuses and asserts he will continue to trust, no matter what.

I'm thinking about Job this morning because I've finished The Road and I think I know why the father refuses to give up on living and why he insists on the same from his son. It's because you never know what may be coming next. "We have to keep going," he says, on almost every page. He's not a merciless taskmaster, they rest when they can, often when the son wishes. But he's a determined one and he reminds himself it's because his son will die without him. And that is true.

There are times when the father wishes he was already dead because there is neither rhyme nor reason to go on except that this is what they must do. It's wet and they need to camp; they're hungry and have to find food; they're in danger and he must protect his son. It doesn't make sense and when they nearly despair of going further, they discover an oasis that almost seems as though it was left, just for them, by an unseen and unknown traveler who knew they'd come this way.
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Life does that to us. Leaves provision when none is expected and where many fail to look. We believe we're starving and perhaps we are, but one does not always live by bread alone. McCarthy tells us it's more than the life of his son, it's the charge given him by his wife to care for their son. He gave his word and in the darkness his words and the spectre of his wife come back to haunt him. What are we doing this for? asks his son. I don't know, he replies, but we have to keep going.

Ultimate meaning and purpose are unclear, but dying is not an option. The father tells his son I don't know what we'll find when we get to the coast, but we have to get there. It's an answer to the age-old question of why we're here. We may not know why, all we know is we are, and what we do in the meantime has significance because we're alive and that's sufficient reason to keep going.

The hope McCarthy describes is not the namby-pamby, pie in the sky by and by kind that whispers sweet nothings in your ear because it's impotent to deliver the goods. I'm not sure his characters ever use the word. But throughout the story they retain the belief that they're the "good guys" and like physicians, have sworn to do no harm. However they come out by the end of the road, they're coming out clean.

Integrity and fulfilling one's moral obligations are recurring themes in McCarthy's books and in The Road he declares they have an importance in excess of survival at any cost. What appears as weakness has unmeasurable strength. We may feel as though we've been thrown into an unpredictable and meaningless chaos where dog-eat-dog is the rule because resources are limited and anyone who believes otherwise is a fool. The Road tells us there are better ways to live and those who choose them will not be disappointed.


(Creative Commons image entitled "The Road" by petar_c via Flickr)

To the New First Years

A friend of mine once said, "Cockroaches are tender-hearted. One dies and a million comes to its funeral." Advice for first-time medical students tends to be as prolific. Once you announce your admission, semi-serious and tongue-in-cheek comments range from "Is it too late to back out?" to "'C' is the correct answer for every test question you'll ever get." A lot of it is general, all of it is well-intentioned, but only some of it is really useful. What is most useful seems to come by experience and what follows has been mine.

To begin with, medical school, like the real world of medicine, is a communal endeavor. The person standing next to you in anatomy lab may turn out to be a valued colleague, even though at the moment they're struggling to keep their head above water. Competition was fine as a premed but now you have more important concerns than who's on first. Students committed to helping one another make lasting friends as well as a lasting impression, so be sure yours is a good one.

Second, despite the fact that you're about to be inundated with information, more than anyone could possibly absorb, digest, and retain, you will learn some things and you'll be surprised at how much. Not all of it is testable, however, and your mission, since you've chosen to accept it, involves ferreting out what is from what isn't. Make no mistake, this is a critical skill and the first week is not too soon to get coaching from upper classpersons about how to do it well.

Third, not everyone learns in the same way. There are students I've admired who can memorize in their sleep. Others are process-learners who need to explain and talk through the material. If you're one of these, don't tell yourself you have to know something before you describe it to a friend. Use your notes -- your instructors do. The point is to get the concepts into your head by whatever means, so they are available when you need them.

Fourth, I was about to say, don't wait until you're in trouble to ask for help, but I've changed my mind. It's difficult for medical students to admit to themselves, much less someone else, that things aren't going like expected. We have high expectations for our performance and assume others do as well. Getting past denial and facing the truth is tough. Just don't wait until you're in deep trouble to become honest with yourself. Trust me, as much as it hurts, you'll feel better once your problems are out in the open and you've got the people you need on your side.

Finally, even though I said medical school is a communal endeavor, it's also an individual one. For each of us, this is a once-in-a-lifetime experience that truly does go by, way too fast. It's incredibly precious -- gobble it up, enjoy it, revel in it. After four or five or however many years it takes, you'll be in residency because of what you've accomplished. Don't ever take it for granted and don't ever let it get old.


(Creative Commons image of the University of New England by Harmoney via Flickr)